Breaking the cycle: public health perspectives on interpersonal violence in the Russian Federation

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Breaking the cycle:

public health perspectives on

interpersonal violence in the Russian Federation

Policy Briefing

VIOLENCE AND INJURY PREVENTION PROGRAMME

Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. E-mail: postmaster@euro.who.int Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark

World Health Organization Regional Office for Europe

Web site: www.euro.who.int

The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for

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5063134 E89855 Original: English

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Breaking the cycle: public health perspectives on

interpersonal violence in the Russian Federation

Policy briefing

Violence and Injury Prevention Programme WHO Regional Office for Europe

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ABSTRACT

Interpersonal violence is a major public health problem in the Russian Federation. Levels of violent mortality increased dramatically in the early 1990s. By 2002, violence was the sixth leading cause of death in the Russian Federation and accounted for almost 1.5 million disability-adjusted life-years. The violent mortality rate was three times higher than the global average. This places a huge burden not only on health but also on social and economic development. This publication outlines the extent and effects of violence in the Russian Federation, including youth violence, intimate partner violence, sexual violence, child maltreatment and elder abuse. It identifies the risk factors for perpetrators and victims of these different forms of violence, including the important role of alcohol in homicide and assault, and discusses prevention measures that can be effective in reducing violence. Proposing a public health approach to tackle violence, the publication outlines key actions to help agencies in the Russian Federation implement measures to prevent violence.

Keywords

INTERPERSONAL RELATIONS VIOLENCE - prevention and control

WOUNDS AND INJURIES - prevention and control SPOUSE ABUSE

CHILD ABUSE ADOLESCENT DOMESTIC VIOLENCE SEX OFFENSES RISK FACTORS HEALTH POLICY RUSSIAN FEDERATION EUROPE

EUR/06/5063134

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© World Health Organization 2007

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area”

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The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. The views expressed by authors or editors do not necessarily represent the decisions or the stated policy of the World Health Organization.

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This document has been produced by:

Violence and Injury Prevention Programme

WHO European Centre for Environment and Health, Rome WHO Regional Office for Europe

Via Francesco Crispi, 10 I-00187 Rome

Italy

Tel.: +39 06 487751 Fax: +39 06 4877599

E-mail: violenceinjury@ecr.euro.who.int Web site: www.euro.who.int/violenceinjury

Responsible: Dr Inge Baumgarten, Technical Officer Violence Prevention

In collaboration with:

Professor Mark A. Bellis, Karen Hughes and Sara Hughes Centre for Public Health

Faculty of Health and Applied Social Sciences Liverpool John Moores University

Liverpool, L3 2AY

United Kingdom of Great Britain and Northern Ireland Web site: www.cph.org.uk

This publication was prepared with the support of the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH, WHO Collaborating Center on Health Systems Development

Other contributors and reviewers:

Martin McKee, London School of Hygiene and Tropical Medicine, London, United Kingdom

Kari Paaso, WHO Regional Office for Europe, Copenhagen, Denmark

William Alexander Pridemore, Indiana University, Bloomington, United States Remigijus Prochorskas, WHO Regional Office for Europe, Copenhagen, Denmark Francesca Racioppi, WHO European Centre for Environment and Health, WHO Regional Office for Europe, Rome, Italy

Viktoria G. Semyonova, Central Research Institute of Public Health, Russian Federation Ministry of Health and Social Development, Moscow, Russian Federation Dinesh Sethi, WHO European Centre for Environment and Health, WHO Regional Office for Europe, Rome, Italy

Vladimir Shkolnikov, Max Planck Institute for Demographic Research, Rostock, Germany

Elena Varavikova, World Health Organization, Geneva, Switzerland Text editing: David Breuer

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COCONNTTEENNTTSS

Page

1. Introduction ...1

2. Magnitude of the problem ...1

Youth violence: violence between young people ...2

Intimate partner violence: violence occurring within an intimate relationship...3

Sexual violence: sexual assault, unwanted sexual attention and sexual coercion ...3

Child maltreatment: violence and neglect towards children by parents and carers ...3

Elder abuse: mistreatment or neglect of older people by family or caregivers...4

Risk factors ...5

3. Type of violence ...6

Bold = risk factors confirmed through research in the Russian Federation. Within the table, where risk factors are specific to either victims or perpetrators they are marked with a (V) and (P) respectively. ...6

Effects of interpersonal violence ...7

Prevention ...7

Type of violence ...8

Type of intervention...8

A public health approach to preventing violence...9

References ...11

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page 1

1. Introduction

Although much violence is preventable (1), interpersonal violence (Box 1) remains a significant public health problem in the Russian Federation. Levels of violent mortality increased dramatically in the early 1990s (2,3) and today remain among the highest in the world (4), placing a huge burden on health as well as social and economic development. Violence has contributed substantially to both decreasing life expectancy and declining population levels (5,6).

Thus, in 2003, life expectancy was 64.9 years, the lowest in the European Region, with the population decreasing by almost 5 million since 1990 (to 143.4 million in 2003) and being expected to fall by a further 9 million by 2015 (7). The economic and social upheaval experienced in the Russian Federation since the USSR dissolved has played an important role in increasing levels of violence. However, while economic conditions are improving in some areas, levels of violence and other health problems show no signs of abating. This publication outlines the extent, effects and risk factors for interpersonal violence in the Russian Federation, discusses prevention measures and highlights the need for a public health approach to preventing violence.

2. Magnitude of the problem

Levels of violence have increased dramatically in the Russian Federation since the late 1980s (Box 2). In 2002, violence was the fourth leading cause of disability-adjusted life-years (DALYs) lost in the Russian Federation and the sixth leading cause of death (7). Almost 1.5 million DALYs were lost through interpersonal violence (4), with at least 45 000 individuals dying through assault and homicide. The mortality rate for assault and homicide, at 29.7 per 100 000 population (50.1 for males and 13.2 for females) (2), was more than three times higher than the global rate and the highest rate in the European Region (1,2).

Box 1. Interpersonal violence

Interpersonal violence is that committed between individuals or small groups of individuals and includes physical and sexual assault, emotional and mental abuse, and neglect. Interpersonal violence can be categorized into youth violence, intimate partner violence, sexual violence, child maltreatment and elder abuse (1).

Box 2. Trends in homicides in the Russian Federation

Between 1988 and 1994, the homicide rate in the Russian Federation increased by 350% (8). Although it then declined until 1998, it increased again significantly up to 2001 and has remained relatively steady since. The nature of homicide has also changed.

Perpetrators are now less criminally experienced, and a greater proportion of homicides involve aggravating circumstances, such as being committed by a group, as part of an armed robbery or to conceal another crime (9).

Within the Russian Federation, homicide rates vary widely and are generally higher in the eastern regions (Fig. 1). In 2000, the highest rate (134.4 per 100 000 population in the Republic of Tyva) was more than 20 times higher than the lowest rate (6.5 per 100 000 in the Republic of Kabardino-Balkaria) (8). Police records from the Udmurt Republic (1989–1991) found that two thirds of all homicides were committed by acquaintances, most commonly the consequence of an acute argument; one fifth of female victims were killed by intimate partners (8).

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Breaking the cycle: public health perspectives on interpersonal violence EUR/06/5063134 in the Russian Federation

Policy briefing page 2

Fig. 1. Age-standardized homicide mortality rates per 100 000 population in regions in the Russian Federation, 2000 (8)

Fatal violence represents just a small proportion of overall violence. For example, international evidence shows that, for every youth homicide, between 20–40 victims of nonfatal youth violence require hospital treatment (1). Added to this are many more victims who do not seek or require health care. The following sections provide data and research findings on the prevalence of different forms of violence in the Russian Federation.

Youth violence: violence between young people

• In 1999, people 18–29 years old committed 38% of all homicide offences, 36% of serious bodily harm offences and 64% of assaults (10).

• Among people 14–29 years old, convictions for murder increased from 8500 to 12 300 and for serious bodily harm from 14 200 to 22 100 between 1996 and 2002 (10).

• Between 1991 and 1999, arrest rates among people 14–17 years old for serious assault rose from 13.0 to 17.8 per 100 000 population and for armed robbery from 27.4 to 51.9 per 100 000 (11).

• Among students aged 14–17 years in Arkangelsk, 26% had suffered moderate violence (such as being beaten up or mugged or experiencing threats of serious physical harm) and 3%

severe violence (attacked with a knife, seriously wounded or shot at with a gun) in the past year (12).

• Violence by racist or fascist groups (mainly comprising young, white, unemployed men) is also a problem in the Russian Federation, with recent reports of attacks (including murder) on ethnic and national minorities as well as foreign citizens (13).

7–17 18–28 29–43 44–70 71–134

No data available

Homicide rate per 100 000

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Intimate partner violence: violence occurring within an intimate relationship

• Each year an estimated 12 000 to 16 000 women are killed by intimate partners (14–16).

• A study of 2100 married people in seven regions (and 50 localities) in the Russian Federation in 2002 found that more than half the wives reported at least one incident of physical

violence from their current husbands. Thirteen percent had been hit while pregnant, sick, nursing or in distress (17).

• Intimate partner violence is not limited to women; a study across nine regions found that 23% of men had experienced physical violence (beatings, blows and shoves) in an intimate relationship (15).

• In 1997, more than 3000 men were killed by their wives; in most cases the offender herself had suffered ongoing abuse prior to the homicide (18).

• Few victims of intimate partner violence seek help from authorities; one study found that 5%

of female victims sought medical help and 19% police protection but that half reported needing but not seeking any support (17).

Sexual violence: sexual assault, unwanted sexual attention and sexual coercion

• In 2002, 5600 rapes and 3200 cases of sexual harassment were registered in the Russian Federation (10).

• Between 1990 and 1996, recorded offence rates for rape fell from 10.1 to 1.3 per 100 000 population, compared with an increase from 6.0 to 6.6 in the mean rate in the 34 countries in the Council of Europe for which data were available (19). However, even the authorities do not think that this reflects the real situation (11,20), and less than 10% of rapes are thought to be reported to the police (21,22).

• In St Petersburg, one in ten women aged 15–17 years surveyed had been raped (23).

• Among adolescent females, one in four report their first sexual encounters to have been forced or unwanted (24).

• Trafficking of Russian women for sex work abroad has increased in recent years (25); many victims believe they are travelling abroad for paid work yet on arrival are forced into sex work, often through violence (26). The Russian Federation is also a destination country for women trafficked from other countries, such as Kyrgyzstan (1).

Child maltreatment: violence and neglect towards children by parents and carers

• In 2002, official statistics showed that 3300 children and adolescents died and 3900 suffered severe injury through violent crime (10). However, each year parents mistreat an estimated 2 million children younger than 14 years (10).

• A study of children aged 11–16 years in eastern Siberia found that 29% had experienced parental punishment deemed abusive by researchers, with 4% requiring health care due to injury inflicted by parents (27).

• Official crime data show that cases of neglect (non-performance of parental duties) increased from 1313 in 1997 to 2751 in 2002 (10). Further, the number of children younger than 18 years living without parents increased from 426 000 in 1992 to 639 000 in 2000, and more

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than 90% are “social orphans”, who have parents who are unable or unwilling to care for them (10).

• Crime data show that sexual abuse of children declined from 1997 (from 542 to 175 reported cases in 2002). However, this reflects a reduction in the age of consent from 16 to 14 years in 1998, meaning that sexual acts with 14-year-olds are no longer classified as abuse (10).

Moreover, child abuse hotline statistics suggest that only 1% of the cases of child sexual abuse are reported to the police (28).

• Levels of child prostitution, trafficking and pornography have escalated in recent years;

between 20–30% of Moscow’s street children are thought to be involved in prostitution or pornography, and the Russian Federation is now considered one of the world’s largest sources of child pornographic material (29).

• Physical violence by family members is a frequent cause of children leaving home. In a survey among street children in the Russian Federation, 63% of the children were from violent homes and 2% left because of sexual harassment by their father, stepfather or mother’s male partner (30).

Elder abuse: mistreatment or neglect of older people by family or caregivers

• Almost one fifth of the population is aged 60 years or more (most of whom are women), but little is known about the prevalence of elder abuse (10). However, internationally, the prevalence of elder abuse in non-institutional settings has been found to range between 4%

and 6%, with levels of abuse in institutional settings thought to be higher (1).

• Homicide mortality rates in the Russian Federation are highest in age groups from 35–54 years and remain at relatively high levels even among people older than 65 years (31). This contrasts with many other countries, such as England and Wales (32) and the United States (31), where rates tend to peak in younger age groups and drop with age.

• Although not classified as interpersonal violence, suicide in the Russian Federation has been associated with neglect and other forms of abuse. For both males and females, suicide rates are highest among people 80 years and older (33).

Although information is scarce, abuse within institutions such as the police, state orphanages, armed forces, prisons, juvenile detention centres and psychiatric institutions throughout the Russian Federation is becoming more widely recognized and contributes to all forms of violence.

For instance, a recent report by Human Rights Watch (34) documented the harsh treatment of new recruits to military services experienced under the dedovshchina system, an informal hierarchy of conscripts based on their length of service. Here, new recruits are often subjected to constant threats of violence for failing to comply with orders, including severe beatings and sexual abuse. Ill-treatment of criminal suspects has also been recognized as a significant problem within judicial systems in the Russian Federation, where detainees are subject to physical abuse to gain confessions (35). Further, HIV infection has been linked not only to prejudice against those infected while in communities but also to discrimination and neglect of those infected in health care settings (36–38). Recent reports have highlighted the need for effective strategies to adequately deal with such institutional issues and to reform state institutions (39). Illegal drug use in the Russian Federation is not only contributing to increasing levels of HIV infection (40) (and consequent discrimination) but can also be directly linked to violence by influencing the behaviour of users and through criminal activity associated with dealing and supplying.

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Risk factors

International studies have identified a range of risk factors for involvement in different forms of violence, with some being confirmed through literature from the Russian Federation. To help understand the variety of risk factors and how they interact, an ecological model (Fig. 2 (1)) is used to divide factors into those associated with individuals, relationships between individuals, communities and society. Using this model, Table 1 summarizes the risk factors for the different types of violence. Risk factors shown in bold are those confirmed through research in the Russian Federation; all others have only been identified and researched adequately in other countries but are likely to apply in the Russian Federation context.

Fig. 2. The ecological model for understanding violence

For interpersonal violence in general, research into homicides in the Russian Federation has identified several risk factors. Similar to other countries, men are most likely to be both victims and perpetrators. However, unlike many other countries, where homicide rates tend to be highest among young people, in the Russian Federation rates are lower among people younger than 25 years and peak between ages 35–54 years (31). The risks of homicide are greater among those who are unmarried and with lower education levels (41). At the regional level, the proportion of single-parent households, poverty and heavy alcohol consumption (Box 3) have all been associated with increased homicide (42). In the Russian Federation, social capital can have a protective effect on health (43), and social changes occurring during transition (such as economic strain, increased unemployment and reduced societal support) have been considered important contributors to increases in a range of health problems, including violence (11,44,45).

Nevertheless, economic improvements within the Russian Federation since the economic downturn in 1998 have not been accompanied by any significant fall in the rate of violence, with homicide and suicide mortality remaining high (2). For violence against women in particular, research (14,46) has implicated traditional and neo-traditional gender roles in the Russian Federation and beliefs that family violence is a private matter in intimate partner violence.

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Box 3. Alcohol and violence in the Russian Federation

Many acts of violence involve the use of alcohol, suggesting that heavy alcohol consumption and violent behaviour are closely related (47). For instance, among individuals arrested for homicide in the Russian Federation during 1995, about three quarters were under the influence of alcohol (48). In the Central Black-Earth Region, 77% of offenders of violent crime were frequent drinkers (49). Further, reductions in alcohol consumption reported in Moscow during the anti-alcohol campaign in the mid-1980s were accompanied by a fall in the level of violent deaths (50). Evidence suggests that a culture of binge-drinking, coupled with a preference for spirits over beverages with lower alcohol content, allows for quicker, more intense intoxication and plays an important role in fuelling alcohol-related violence (51). Analysis of homicides in the Udmurt Republic found that deaths peak on Fridays and Saturdays, possibly due in part to heavy alcohol consumption on weekend nights (52). Further, analysis of homicide deaths among native populations in the northern Russian Federation found few differences in weekday rates in areas where alcohol sales were not restricted (western regions), yet where alcohol sales were only permitted on Saturdays (eastern regions), homicides increased sharply on Sundays (53).

Table 1. Risk factors for different types of interpersonal violence

3. Type of violence Youth violence Intimate partner

violence Child abuse Elder abuse Sexual violence

Individual factors

• Male

• Delivery complications at birth

• Personality and behaviour problems

• Low academic achievement

• Low socioeconomic status

• History of childhood abuse

• Substance use

• Female (V)

• Male (P)

• Younger adults

• Low

socioeconomic status

• Alcohol use (P)

• Personality disorders (P)

• Low academic achievement (P)

• Employed (P)

• Working in non- professional occupations (P)

• Premature infants, handicapped children, twins (V)

• Unemployed (P)

• Low education (P)

• Low income (P)

• Personality disorders (P)

• Stress (P)

• Social isolation (P)

• Substance use (P)

• Cognitive or physical impairment (V)

• Financial difficulties (P)

• Alcohol use (P)

• Stress (P)

• Young females (V)

• Alcohol or drug use

• History of sexual assault (V)

• Involvement in sex work (V)

• Increased education and empowerment (V)

• Impulsive or antisocial tendencies (P)

• Hostility towards women (P)

Relationship factors • Poor parental

supervision

• Harsh physical punishment

• Family violence

• Delinquent peers

• Teenage mother

• Single-parent family

• Parents who abuse alcohol or drugs

• Marital conflict

• Poor family functioning

• Male dominance in family

• Family violence in childhood (P)

• Parental conflict

• Large family size

• Single parent family

• Childhood abuse (P)

• Poor patient–caregiver relationship

• Elder living with caregiver

• Caregiver dependence on elder

• Having many sexual partners (V)

• Aggressive peers (P)

• Violence in the family

• Unsupportive family environment

• Childhood abuse

Community and society factors

• Urbanization

• Rapid demographic change

• Income inequality

• High unemployment

• Weak governance

• Weak community sanctions

• Low social capital

• Traditional and neo- traditional gender norms

• Poverty

• Low social capital and investment

• Social isolation (V)

• Culture of ageism, sexism and violence

• Loss of traditional elder roles

• Erosion of family bonds (for instance, through migration to cities)

• Poverty

• Lack of employment opportunities

• Poorly managed police and judicial system

• Gender inequality

• High crime levels

• Social norms supportive of violence

• Cultural acceptance of binge drinking

Bold = risk factors confirmed through research in the Russian Federation. Within the table, where risk factors are specific to either victims or perpetrators they are marked with a (V) and (P) respectively.

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Effects of interpersonal violence

Interpersonal violence has devastating consequences for victims in terms of physical, mental and sexual health. Physical injuries can range from bruising to permanent disfigurement and disability; mental harm includes depression, post-traumatic stress disorder and suicide (54–56) (Box 4). Sexual assault can cause sexually transmitted infections (including HIV, with levels increasing dramatically in the Russian Federation (7)), unwanted pregnancy and sexual dysfunction. Further, experience of violence can increase individuals’ risks of other health- threatening behaviour such as substance use (57). Violence also has far-reaching effects on victims’ families and friends, communities and the wider society. For example, children in the Russian Federation who have witnessed violence in the family show higher levels of mental disorders (58).

Treating the victims of violence places huge demands on health services. Evidence from outside the Russian Federation shows that violence is a major cause of hospital admission among population groups with the highest violence rates, such as young men in the United Kingdom (59). In the Russian Federation, 68 200 people were reported to be seriously injured through criminal violence in 2002 (10), and treatment needs for such injuries create a major burden for health care services. Cost estimates of health care for violence alone are not available. However, external causes (combining injuries, accidents, poisoning and burns) rank third (after circulatory and respiratory diseases) in estimates of health care expenditure, with annual treatment costs of Rub 36.5 billion, or 0.27% of gross domestic product (60). This estimate excludes emergency medical care and medication purchased for home treatment.

Box 4. Suicide

The Russian Federation has one of the highest rates of suicide in Europe. In 2002, more than 55 000 people died from suicide and intentional self-harm (36.4 per 100 000 population (2)), and about 1.3 million DALYs were lost through self-inflicted injuries (4). Much higher rates of suicide are reported among males (67.4 per 100 000 population versus 10.4 per 100 000 population among females in 2002). The suicide rate increased steadily from 1986 onwards, peaking at 42.4 per 100 000 population in 1994 (2). The abolition of the anti-alcohol campaign of the mid-1980s along with the economic, social and political changes of the 1990s may have contributed to these trends (34). However, since then rates have been fluctuating, with a moderate decline in deaths from suicide from 1999 onwards (2).

In addition to direct costs, victims of violence can experience longer, ongoing mental, financial or sexual problems. For example, in a Moscow sexual health centre, four of five women seeking treatment for sexual disorders have a history of rape or attempted rape (10). High levels of violence are also costly to a wide range of agencies outside health services, including criminal justice and social services. Further, increases in the societal fear of violence and crime can reduce community cohesion and hamper social and economic development (60).

Prevention

Much violence can be prevented, and a wide range of interventions is available internationally that can effectively reduce violence in a variety of settings (Table 2). Primary prevention programmes that target parents and children in the earliest stages of life, such as pre- and postnatal services, parenting programmes and school programmes to enhance social development among children and adolescents, can be effective in reducing the risk factors for violence. In

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general, and particularly where levels of violence are increasing, early interventions can play a critical role in breaking escalating cycles of violence that turn childhood victims and witnesses into perpetrators and repeat victims in later life.

Measures to recognize and treat victims of violence, such as training for health staff in identifying and referring victims and providing specialist support services, are not only essential in reducing the health and other consequences of violence but can also help prevent re- victimization. In the Russian Federation, voluntary organizations have led the development of victim services, particularly for women who are victims of intimate partner violence (14).

Table 2. Examples of interventions found to be effective in preventing the risk factors for different forms of violence (1)

Type of violence

Type of intervention

Youth violence Intimate partner violence Child abuse Elder abuse Sexual violence

Increasing access to prenatal and postnatal services + +

+ +

+

+ + +

Home visiting programmes +

+

+ +

Programmes to treat child abuse victims +

+

+ +

+

+ + +

+ Social development training for children and adolescents +

+

+ +

Parenting programmes +

+

+ +

+

+ + +

+ Training health staff in identifying and referring victims +

+

+ +

+ + Strategies for reducing use of alcohol and illegal drugs +

+

+ +

+

+ + +

+

Disrupting illegal gun markets +

+ + + + +

Improving police and judicial systems +

+

+ +

+ + Deconcentrating poverty and reducing inequality +

+

+ +

++: Strong evidence of effectiveness in preventing risk factors for this type of violence.

+: Some evidence of effectiveness in preventing risk factors for this type of violence.

aThe World report on violence and health (1) has further information on these strategies.

At the community level, programmes to reduce alcohol and drug use and disrupt drug markets can be effective in reducing the risk factors for violence. In the Russian Federation, the anti- alcohol campaign undertaken in the 1980s was associated with decreased consumption and a 33% reduction in violent deaths. However, such deaths quickly increased following the end of

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the campaign (50). Although this campaign was unpopular, its success in reducing violence demonstrates the important role of controlling alcohol consumption in preventing violence.

Wider strategies to prevent violence include those to reduce poverty and inequality (both of which are major factors in the Russian Federation (7)) and to improve police and judicial systems. Strategies such as improving social safety nets (such as unemployment benefits) and providing better education and living facilities in deprived areas help distribute resources more evenly, thus addressing inequality (1). Similar to other countries (1), most incidents of violence in the Russian Federation go unreported to judicial services (61,62), and those that are reported may be met with a poor response or be played down by officials (such as intimate partner violence (63)). Consequently, convictions for violence can be the exception. Widespread awareness campaigns combined with strengthened responses to violence and training for health staff, police and community leaders may prove effective as part of a suite of public health measures to prevent violence. Such measures necessitate not only training in police (64) and judicial services but can also require legal reforms such that victims have more confidence reporting violence and seeking support while perpetrators recognize an effective deterrent.

Further, changing the social norms that tolerate violence is essential in creating lasting changes to environments that discourage violence and tackle perpetration.

A public health approach to preventing violence

Fig. 2. The public health approach The public health approach to preventing

violence uses data and research from a wide range of sources and disciplines to provide better understanding of the extent, causes and risks of violence and to develop and widely implement effective interventions (Fig. 2). It aims to provide the greatest benefits to the maximum number of people by instilling prevention measures across populations while ensuring that treatment and care are available and accessible at the individual level. Interventions should be evidence- based; where no evidence is available, they should be accompanied by rigorous

evaluation. However, cost-effectiveness (as well as effectiveness) should influence the choices of interventions as should the availability of resources and capacity with which to deliver interventions, not just within health services but also within other agencies. Joint working is facilitated and maintained by widespread awareness-raising of the benefits of prevention to health, criminal justice and social and economic development. Such an approach routinely requires collective action through partnerships between government, health, criminal justice, education, social services and a wide range of other groups, including voluntary services and community members. For the Russian Federation, key actions for developing the public health approach to preventing violence are:

Surveillance Identifying the size

and scope of the problem

Research Identifying risk and

protective factors

Implementation Implementing successful measures

widely

Development Developing and

evaluating interventions

• developing a national action plan for preventing violence and unintentional injuries;

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• forming an intersectoral committee to ensure that the agendas of government ministries and agencies give priority to preventing violence;

• identifying, reviewing, improving and monitoring existing sources of information on violence to create a more accurate profile of the problem;

• firmly establishing political and legal support for prevention, including access to data, victim support services, responses to perpetrators and primary prevention;

• improving police and other judicial systems so that such services are visibly accessible and responsive to all forms of violence and function as effective deterrents;

• developing a national research agenda for violence that identifies risk factors, the circumstances in which violence occurs and the costs to society, and disseminating the research findings widely;

• developing educational programmes that address violence and preventing it for key personnel including health staff, schoolteachers, police, community leaders, government officials and potential victims and perpetrators;

• evaluating and promoting effective prevention strategies for reducing violence and creating a tailored approach to prevention that recognizes a variety of methods needed for different population groups;

• campaigning to raise awareness of violence as a public health issue, particularly within high- risk groups, and using health, education and judicial mechanisms to address the social, cultural and structural circumstances in which violence currently occurs;

• making basic improvements in health and social services to deal with violence-related trauma, such as preparing emergency departments to respond to violence-related injuries, creating trauma centres within hospital settings and supporting the development of specialist support services within communities;

• promoting a multi-agency approach to prevention facilitated by shared intelligence that underpins a wider understanding of the priorities for preventing violence; and

• advocating for safe physical and societal environments that protect the population from injuries.

WHO and preventing violence

The WHO global campaign for preventing violence, launched in 2002, works to raise international awareness about the problem of violence, highlight the role of public health in its prevention and increase violence prevention activities globally. Their approach is set out in the World report on violence and health (1). World Health Assembly resolution WHA56.24 adopted in 2003 encourages Member States to implement the recommendations set out in the report. The Russian Federation is working closely with WHO internationally and within Europe to develop a public health approach to violence and action based on the WHO recommendations.

For further information, contact: violenceinjury@ecr.euro.who.int.

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References

(1) Krug E et al. World report on violence and health. Geneva, World Health Organization, 2002

(http://www.who.int/violence_injury_prevention/violence/world_report/en, accessed 8 September 2006).

(2) European mortality database [online database]. Copenhagen, WHO Regional Office for Europe, 2006 (http://data.euro.who.int/hfamdb/index.php, accessed 8 September 2006).

(3) Gavrilova NS et al. Patterns of violent crime in Russia. In: Pridemore WA, ed. Ruling Russia: law, crime and justice in a changing society. Oxford, Rowman & Littlefield, 2005:117–146.

(4) Global burden of disease 2002 estimates. Geneva, World Health Organization, 2002

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